PRE-COUSELING SELF REPORT

Name ______________________________ Date ___________________

PERSONAL:

1. What brought you to seek treatment? _____________________________________

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2. What are your goals in counseling? ______________________________________

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3. What have you done about these concerns before coming to counseling?___________

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4. Please share any other information about yourself that would be helpful in the counseling process:

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FAMILY ORIGIN AND HISTORY

1. List siblings and ages:_________________________________________________

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2. Names of parents (biological, adoptive, step, etc.) and ages (note if deceased) ______

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3. Please list any known substance abuse/addictions, depression, anxiety, mental illness, etc. in your family history. __________________________________________________________________

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MARITAL HISTORY

1. Please provide information about your current marriage and any past marriages if applicable. Include year married, length of marriage and children (name, age and custody) from each marriage. ________

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2. Current Living arrangement. ____________________________________________

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PLEASE FEEL FREE TO INCLUDE ANY FURTHER PERTINENT INFORMATION ABOUT YOURSELF ON THE BACK OF THIS PAGE. THANK YOU.